Provider Demographics
NPI:1235335167
Name:CLOSE, JACK D (MAPT,FAPTA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:D
Last Name:CLOSE
Suffix:
Gender:M
Credentials:MAPT,FAPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 S EASTERN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-3379
Mailing Address - Country:US
Mailing Address - Phone:702-731-6873
Mailing Address - Fax:702-731-2565
Practice Address - Street 1:3650 S EASTERN AVE
Practice Address - Street 2:STE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-3379
Practice Address - Country:US
Practice Address - Phone:702-731-6873
Practice Address - Fax:702-731-2565
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV57225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV32404Medicare ID - Type Unspecified